인트라넷 기반의 자발적 의료오류 보고체계의 유용성 = Value of Voluntary Intranet-based Medical Error Reporting System

다국어 초록 (Multilingual Abstract)

Purpose: The emergency department is prone to medical errors due to the patients’acuity and complexity. Collection and monitoring of data on medical errors are essential for setting priorities and improving patient safety.
Methods: Emergency physicians report medical errors voluntarily with an intranet-based error reporting system. The system is confidential and anonymous. Data on medical errors was collected at the emergency department of a tertiary teaching hospital with approximately 76,000 annual visits, during a nine-month period from April to December 2008. The collected data was analyzed prospectively.
Results: Of the 238 reports collected, 204 errors were analyzed.
90.6% of the errors were related to doctors and 21%were related to nurses. Error types were classified into clinical errors (57%), medication errors (7%) and administrative errors (35%). The levels of impact on patients caused by these errors were classified as near-miss in 28 (13%), no harm in 93 (45%), mild harm in 66 (32%), lethal in 5 (2%)and death in 2 (1%) cases. Errors that occurred in the elderly group (over 60 years of age) had more harmful impact than in other age groups (p=0.0003). The causes of these errors were human in 147 (72%), systems in 23(11%) and both human and systems in 34 (17%). Most of these errors were preventable (99%).
Conclusion: Data collected by the intranet-based medical error reporting system is useful to classify and analyze medical errors, and is also essential in the implementation of a patient safety system.

참고문헌 (Reference)

1 김정은, "환자안전 향상을 위한 종합병원의 전산화된 사건보고시스템 운영 실태조사" 대한의료정보학회 10 (10): 379-386, 2004

2 안기옥, "응급실내 의료오류 보고체계의 시범적 운영" 대한응급의학회 18 (18): 218-226, 2007

3 Cohen MR, "Why error reporting systems should be voluntary" 320 : 728-729, 2000

4 Dovey SM, "What should we report to medical error reporting system?" 13 : 322-323, 2004

5 Milch CE, "Voluntary electronic reporting of medical errors and adverse events. An analysis of 92, 547 reports from 26 acute care hospitals" 21 : 165-170, 2006

6 Kohn LT, "To Err is Human: Building a Safer Health System" National Academy Press 28-, 2000

7 Chang A, "The JCAHO patient safety event taxonomy: a standardized terminology and classification schema for near misses and adverse events" 17 : 95-105, 2005

8 Leape LL, "Reporting of adverse events" 347 : 1633-1638, 2002

9 Barach P, "Reporting and preventing medical mishaps: lessons from non medical near miss reporting systems" 320 : 759-763, 2009

10 "Medical errors: focusing more on what and why, less on who" 3 (3): 66-70, 2007

11 Starfield B, "Is US health really the best in the world?" 284 : 483-485, 2000

12 Tighe CM, "Incident reporting in one UK accident and emergency department" 14 : 27-37, 2006

13 Brennan TA, "Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I" 324 : 370-376, 1991

14 Thomas EJ, "Incidence and types of adverse events and negligent care in Utah and Colorado" 38 : 261-271, 2000

15 Reason J, "Human error: models and management" 320 : 768-770, 2000

16 de Vries EN, "Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review" 17 : 216-223, 2008

17 Croskerry P, "Emergency medicine: A practice prone to error?" 3 : 271-276, 2001

18 Suresh G, "Edwards WH, Shiono PH, et al. Voluntary anonymous reporting of medical errors for neonatal intensive care" 13 : 1609-1617, 2004

19 Rowin EJ, "Does error and adverse event reporting by physicians and nurses differ?" 34 : 537-545, 2008

20 McDonald CJ, "Deaths due to medical errors are exaggerated in Institute of Medicine report" 284 : 93-95, 2000

21 Kram R, "Critical incident reporting system in emergency medicine" 21 : 240-244, 2008

22 Holzmueller CG, "Creating the web-based intensive care unit safety reporting system" 12 : 130-139, 2005